Citation Nr: 0709854
Decision Date: 04/04/07 Archive Date: 04/16/07
DOCKET NO. 98-14 650 ) DATE
)
)
On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO)
in St. Petersburg, Florida
THE ISSUES
1. Entitlement to an evaluation in excess of 20 percent for
the service-connected right shoulder impingement.
2. Entitlement to an initial evaluation in excess of 20
percent for the service-connected lumbosacral strain.
REPRESENTATION
Appellant represented by: Texas Veterans Commission
WITNESS AT HEARING ON APPEAL
The veteran
ATTORNEY FOR THE BOARD
G. Jackson, Associate Counsel
INTRODUCTION
The veteran served on active duty from March 1992 to February
1997.
This matter initially came to the Board of Veterans' Appeals
(Board) on appeal from the January 1998 and February 2000
rating decisions by the RO.
The Board remanded this case back to the RO in July 2000 and
December 2003 for further development of the record.
The veteran testified before a Decision Review Officer (DRO)
in a hearing at the RO in June 2006.
FINDINGS OF FACT
1. The service-connected right shoulder impingement syndrome
is shown to be manifested by MRI evidence of high-grade
partial insertional tear of the anterior leading edge of the
supraspinatus with some functional loss due pain; limitation
of movement or functional loss due to pain of the major arm
below shoulder level is not demonstrated.
2. The service-connected lumbosacral strain is shown to be
manifested by spinal stenosis with mild degenerative changes,
but more than slight loss of motion with pain at the extremes
is demonstrated; neither severe functional loss due to pain
nor limitation of flexion to 30 degrees or less is not shown.
CONCLUSIONS OF LAW
1. The criteria for the assignment of an evaluation in
excess of 20 percent for the service-connected right shoulder
impingement have not been met. 38 U.S.C.A. §§ 1155, 5103,
5103A, 5107, 7104 (West 2002 & Supp. 2005); 38 C.F.R.
§§ 3.159, 4.1, 4.40, 4.45, 4.7, 4.71a including Diagnostic
Codes 5200-5203 (2006).
2. The criteria for the assignment of an evaluation in
excess of 20 percent for the service-connected lumbosacral
strain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A,
5107, 7104 (West 2002 & Supp. 2005); 38 C.F.R. §§ 3.159, 4.1,
4.40, 4.45, 4.7, 4.71a including Diagnostic Codes 5235-5243
(2006); 38 C.F.R. § 4.71a including Diagnostic Codes 5285-
5295 (2002).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
I. VA's Duties and Applicable Regulations
On November 9, 2000, the Veterans Claims Assistance Act of
2000 (VCAA), (codified at 38 U.S.C.A. §§ 5100, 5102, 5103,
5103A, 5107) became law. The regulations implementing the
VCAA provisions have since been published. 38 C.F.R.
§§ 3.102, 3.156(a), 3.159, 3.326(a).
In this case, the Board finds that all relevant facts have
been properly developed in regard to the veteran's claim, and
no further assistance is required in order to comply with
VA's statutory duty to assist him with the development of
facts pertinent to his claim. See 38 U.S.C.A. § 5103A; 38
C.F.R. § 3.159.
Specifically, the RO has obtained records of treatment
reported by the veteran and has afforded him comprehensive VA
examinations addressing his claimed disorder. There is no
indication from the record of additional medical treatment
for which the RO has not obtained, or made sufficient efforts
to obtain, corresponding records.
The Board is also satisfied that the RO met VA's duty to
notify the veteran of the evidence necessary to substantiate
his claims in August 2003 and May 2004 letters. By these
letters, the RO also notified the veteran of exactly which
portion of that evidence was to be provided by him and which
portion VA would attempt to obtain on his behalf. See
Quartuccio v. Principi, 16 Vet. App. 183 (2002).
In these letters, the veteran was also advised to submit
additional evidence to the RO, and the Board finds that this
instruction is consistent with the requirement of 38 C.F.R.
§ 3.159(b)(1) that VA request that a claimant provide any
evidence in his or her possession that pertains to a claim.
Recently, in Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir.
2006), the United States Court of Appeals for the Federal
Circuit (Federal Circuit) held that while the VCAA notice
need not be contained in a single communication, post-
decisional documents (e.g., Statements or Supplemental
Statements of the Case) cannot satisfy the duty to notify.
The Federal Circuit further held that such notice should be
sent prior to the appealed rating decision or, if sent after
the rating decision, before a readjudication of the appeal.
Id.
The requirements for adequacy of VCAA notice were further
clarified by the United States Court of Appeals for Veterans
Claims (Court) in Mayfield v. Nicholson, 20 Vet.App. 537
(2006). In this decision, the Court determined that VCAA
notification did not require an analysis of the evidence
already contained in the record and any inadequacies of such
evidence, as that would constitute a preadjudication
inconsistent with applicable law.
Additionally, the Court found that a Supplemental Statement
of the Case, when issued following a VCAA notification
letter, satisfied the due process and notification
requirements for an adjudicative decision as required under
the Federal Circuit's Mayfield decision.
Here, the noted VCAA letter was issued subsequent to the
appealed January 1998 and May 2000 rating decisions.
However, the RO readjudicated these claims in subsequent
Supplemental Statements of the case (SSOC).
The Board is also aware of the considerations of the United
States Court of Appeals for Veterans Claims (Court) in
Dingess v. Nicholson, 19 Vet. App. 473 (2006), regarding the
need for notification that a disability rating and an
effective date for the award of benefits will be assigned if
service connection is awarded.
By a March 2006 letter the RO notified the veteran of the
evidence necessary to establish both disability ratings and
effective dates in compliance with these requirements. Id.
Accordingly, the Board finds that no prejudice to the veteran
will result from an adjudication of his claim in this Board
decision. Rather, remanding this case back to the RO for
further VCAA development would be an essentially redundant
exercise and would result only in additional delay with no
benefit to the veteran. See Bernard v. Brown, 4 Vet. App.
384, 394 (1993); see also Sabonis v. Brown, 6 Vet. App. 426,
430 (1994) (remands which would only result in unnecessarily
imposing additional burdens on VA with no benefit flowing to
the veteran are to be avoided).
Disability ratings are determined by applying the criteria
set forth in VA's Schedule for Rating Disabilities. Ratings
are based on the average impairment of earning capacity.
Individual disabilities are assigned separate diagnostic
codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1.
In cases where entitlement to compensation has already been
established and an increase in the disability rating is at
issue, it is the present level of disability that is of
primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58
(1994).
However, in cases in which a claim for a higher initial
evaluation stems from an initial grant of service connection
for the disability at issue, in this case the evaluation for
the lumbosacral strain, multiple ("staged") ratings may be
assigned for different periods of time during the pendency of
the appeal. See generally Fenderson v. West, 12 Vet. App. 119
(1999).
Where there is a question as to which of two evaluations
shall be applied, the higher evaluation will be assigned if
the disability picture more nearly approximates the criteria
required for that rating. Otherwise, the lower rating will
be assigned. See 38 C.F.R. § 4.7.
II. Factual Background
The RO granted service connection for the right shoulder
impingement in a June 1997 rating decision and assigned a
noncompensable evaluation. The RO deferred a decision on the
back disorder until after a VA examination.
In a January 1998 rating decision, the RO increased the
evaluation for the service-connected shoulder impingement to
20 percent as of the original date of claim. The RO also
granted service-connection for lumbosacral strain and
assigned a noncompensable evaluation.
The veteran filed a timely Notice of Disagreement (NOD) with
regard to the assigned evaluation for the lumbosacral strain
in June 1998. The RO issued a Statement of the Case (SOC)
and the veteran perfected his appeal regarding the issue of
an increased evaluation for the service-connected lumbosacral
strain in August 1998.
Following the September 1999 remand action, the veteran was
afforded an updated VA examination in January 2000. In
February 2000, the RO increased the evaluation for the
service-connected lumbosacral strain to 20 percent as of the
original date of claim.
As noted, since this increase did not constitute a full grant
of the benefit sought, the veteran's claim for an increased
evaluation remains on appeal. See AB v. Brown, 6 Vet.App. at
39 (1993).
Moreover, the veteran filed a claim for an increased
evaluation for his service-connected right shoulder
impingement in January 2000. The RO denied entitlement to an
increase in May 2000 and the veteran filed a timely NOD in
June 2000. The veteran perfected his appeal regarding the
issue of an increased evaluation for the service-connected
right shoulder impingement in October 2005.
From August 1998 to January 1999, the veteran received
treatment for his back disorder at both a VA and private
medical facility. In a January 1999 treatment record, the
veteran reported that he injured his back when he slipped and
fell walking to work. He complained of having lower back
pain, but denied any numbness, tingling, weakness, bowel or
bladder problems. He reported that he was using heating pads
to treat the pain.
On examination, the veteran had good alignment in the back,
but did have limitation in flexion. He had mild tenderness
in the lumbar area. Straight leg raises were negative.
There was no swelling or edema. There was good full
sensation and no noted weakness. Heel to toe walk was
intact, as were reflexes of the knee and ankle. The gait was
slightly atalgic but without ataxia noted.
The veteran was diagnosed with strain of the lower back. The
veteran was prescribed medication for the pain and advised to
ice and heat his back as needed. He was also given back
flexion exercises to do.
From September 1999 to December 1999, the veteran received
treatment for his right shoulder impingement in a private
medical facility. In the September 1999 record, the veteran
complained of having right shoulder pain. He reported
sustaining an external rotation abduction injury to his
shoulder.
The X-ray studies were negative for fractures, dislocations
or other significant bony abnormalities. He reported a
history of rotator cuff tendonitis during his military
service. He denied any radiation down his shoulder or
numbness or tingling.
On examination, the veteran demonstrated tenderness in all
ranges of motion. He had full range of motion, but had pain
at extremes of forward elevation and abduction. He had pain
with any attempted anterior, inferior or posterior
instability tests. He was able to hold his arm up against
gravity and against resistance. He was diagnosed with
questionable subluxation of the shoulder with an excellent
mechanism versus aggravation of a rotator cuff tendonitis.
In the December 1999 record the veteran complained that his
whole shoulder hurt. He also complained of radiating pain
down his arm, however he had no numbness or tingling. He
described the disorder as feeling like the shoulder went in
and out of joint.
On examination, the shoulder appeared to be located. There
was no gross laxity. He had full range of motion. He was
well muscled with no evidence of any atrophy. Further, there
was no rotator cuff tear or tendonitis.
The examiner concluded that the veteran suffered from
possible residual strain versus subluxation of the shoulder.
He recommended aggressive therapy and prescribed anti-
inflammatory medication.
From January 2000 to October 2003, the veteran received
treatment in a VA medical facility for his low back and right
shoulder disorders.
During a January 2000 VA examination, the veteran reported
that he fell from a truck in 1995 and injured his back and
shoulder. Since that time he claimed to have low back pain.
He underwent several months of physical therapy in 1996
without significant relief of his back pain.
The X-ray studies at the time revealed no fracture,
dislocation or degenerative changes. He was diagnosed with
bad muscle sprain.
The veteran reported that he was prescribed pain medications
for his back condition, but currently was not taking any of
the prescribed medication. He used a heating pad to relieve
the back pain. He reported the pain as a constant pain in
his low back that was worse on the left side.
The pain was aggravated by such activities as lifting,
bending and prolonged walking or sitting. During
exacerbations of pain, the veteran reported that his job
activities and activities of daily living were limited. He
denied radiation of pain to the lower extremities.
Additionally, he denied bowel and bladder incontinence.
On examination, the veteran demonstrated a normal, symmetric
and stable gait. He took small steps during walking. He was
able to bilateral toe and heel walk without any difficulty.
His lumbar spine was without gross deformity.
He had limitation in range of motion with flexion to 60
degrees, extension to 25 degrees, and lateral flexion to 25
and 30 degrees on the right and left, respectively. He had
severe tenderness on palpation in the paraspinal area at L4-5
on the left side.
The examiner noted the range of motion of the lumbar spine
was limited because the veteran was experiencing severe pain
in range of motion testing. His range of motion was
decreased with repetitive motion. In general, the examiner
found that the veteran had left low back paraspinal pain and
tenderness with muscle spasms in that area.
There was no radiation of pain to the lower extremities.
Stress test was negative, bilaterally. However, his straight
leg raise testing on the left side aggravated the pain on his
left paraspinal area. Sensation in the lower extremities was
full and intact.
The diagnosis of low back muscle strain was confirmed. As
noted, the examiner commented that the range of motion in the
lumbar spine was additionally limited by severe pain, fatigue
and repetitive movement. There was no evidence of
incoordination. The veteran was unable to run and had to
walk with a slow gait.
In a January 2003 VA treatment record, the veteran reported
having a history of right shoulder pain status post surgery
and low back pain as a result of an accident in service. He
complained that he was unable to sit more than thirty
minutes. He denied any paresthesis, numbness or urinary
problems. He was not on any medication.
On examination, the veteran was unable to flex, extend or
rotate his spine without having pain. His ability to sit
down in and rise from a chair was markedly compromised. He
was diagnosed with chronic low back pain superimposed with
acute low back pain.
The veteran was to refrain from work for two weeks. He was
advised to apply ice and moist heat to his low back to
relieve the pain. Additionally, he was prescribed pain
medication for his back pain.
In the October 2003 treatment record, the veteran complained
of progressively worsening pain between his shoulder blades
and low back since August 2003. He also reported an
occasional numbness and tingling down his left leg. He
complained that he could not walk long distances without
taking muscle relaxers.
On examination, the veteran had tenderness over the
paravertebral muscles T2-T5 and L4-S1. He had no
deformities, ecchymosis or erythema noted. He had full range
of motion in all extremities. Neurovascular status of
extremities was intact.
From February 2005 to February 2006 the veteran received
treatment at the VA medical facility for his back and right
shoulder disorders. During an April 2005 VA examination, the
veteran reported a constant, moderate pain in his upper
lumbar back. He reported that he experienced flares of pain
after overexertion.
He worked in construction, tagging beams. Due to his back
condition, he was given a lighter job as cleanup guy and
worked only part time five days a week. He reported that his
flares of back pain required a day and a half of bed rest.
The veteran experienced an occasional numbness in his left
leg that lasted only a few minutes. He wore a back brace
when he went to work and used an assistive device. He took
prescribed medication to help relive the pain while he was at
work. He could not walk a mile, stand for an hour, or sit
for more than sixty minutes without back pain.
On examination, his gait and posture were normal. There was
a paraspinal muscle spasm on the left side. He was tender on
palpation on the upper lumbar or lower thoracic area. He had
forward flexion to 65 degrees, backward extension to 20
degrees with pain, lateral flexion to 30 degrees,
bilaterally, with pain at extremes, and lateral rotation to
30 degrees, bilaterally.
There was no additional limitation of motion after repetitive
movement, nor was there weakened movement, easy fatigability,
lack of endurance or incoordination.
The veteran's motor strength in the lower extremities was
full, and sensation was intact. He could not play sports
anymore because of his back disorder, but the rest of his
activities of daily living were not affected by his back
pain. Bowel, bladder and sex function were not affected.
The back pain did not radiate into the extremities.
The X-ray studies of the lumbar spine was negative. There
was no acute fracture or dislocation of the lumbar spine.
The veteran was diagnosed with lumbar strain.
A July 2005 MRI of the lumbar spine showed that alignment of
the lumbar spine appeared normal. There was a diffuse
moderate congenital lumbar canal stenosis. At the L3-L4 and
L4-L5 levels, there was mild broad based disc bulges. Mild
bilateral facet hypertrophy caused the moderate central canal
stenosis and mild narrowing of the neural foramina. The
conclusion was that the veteran suffered from mild
degenerative disease of the lumbar spine, superimposed on the
moderate congenital lumbar canal stenosis.
An MRI of the right shoulder showed that the
acromioclavicular joint demonstrated no significant
osteophytic spurs or fibrous overgrowth of the capsule. The
acromion had a roughening to its undersurface, was horizontal
in its orientation, and level with the clavicle.
The evaluation of the rotator cuff demonstrated a partial
undersurface tear at the anterior leading edge with fraying
and fibrillation of the tendon. High T2 signal within the
distal tendon near its insertion on the greater tuberosity
was present suggestive of a small full thickness tear. His
rotator cuff muscles were normal in size and signal
intensity, and rotator cuff interval, glenoid labrum and
glenohumeral ligaments were normal.
There were no significant osseous abnormalities. Bone marrow
was normal with no evidence of fracture or degenerative
changes. The articular cartilage of the glenohumeral joint
was normal. There was a small subacromial bursal collection
present. There was evidence of axillary adenopathy or masses
or suprascapular nerve entrapment.
The veteran was diagnosed with high grade partial insertional
tear at the anterior leading edge of the supraspinatus tendon
with findings suspicious for a small full thickness tear near
its insertion.
During a September 2006 VA examination, the veteran
complained of increasing pain in his right shoulder. He
reported that the pain ranged in intensity from 3-10 out of
10 and that he had weakness, stiffness and swelling of the
right shoulder.
He had an occasional giving away of the shoulder. He did not
have a history of locking. He took over-the-counter
medication to treat the pain, but had previously been
prescribed medication for the pain.
The veteran had flares of pain when he used the right upper
extremity on a daily basis that lasted two to three hours.
Flares of pain were relieved by rest and medication. During
flares of pain use of the upper extremity was very limited
and restricted which affected his activities of daily living.
He reported that pain in his back was more localized from the
thoracic region down to the lumbar region. He reported that
the pain in his back was also becoming worse with intensity
ranging from 7-10 out of 10. Advil and Tylenol provided
partial relief of his pains.
The flares of pain were precipitated by standing in excess of
one hour or sitting more than 45 minutes. Flares occurred
every two days and lasted several hours. Flares of pain were
relieved with medication or his lying on his back or stomach
with his legs elevated.
The veteran reported having an intermittent numbness of the
whole right lower extremity and occasional weakness of the
right leg. He denied having any bladder or bowel
incontinence or sexual dysfunction.
The veteran used a cane for ambulation and had a back brace
that he used on an as needed basis. His back condition did
not interfere with activities of daily living, and he had not
had any incapacitating episodes in the past twelve months.
An examination of his right shoulder showed no wasting of the
supraspinatus or scapular musculature. He had slight
crepitus over the right shoulder. He was tender on palpation
of the greater tuberosity of the humerus at the insertion of
the supraspinatus. He had a positive impingement test.
Neurovascularly, the veteran's right upper extremity was
intact. His range of motion testing revealed forward flexion
0 to 130 degrees with pain at 90 degrees; abduction 0 to 130
degrees with pain at 90 degrees; external rotation to 0 to 90
degrees without pain; and internal rotation 0 to 45 degrees
with pain at 45 degrees.
The range of motion testing in the thoracolumbar spine
revealed flexion 0 to 70 degrees with pain at 70 degrees;
extension 0 to 20 degrees with pain at 20 degrees; lateral
rotation and lateral flexion 0 to 30 degrees bilaterally
without pain.
The straight leg raising test was positive for back pain,
bilaterally. There were no sensory, reflex or motor defects.
Additionally there was no thoracolumbar spasm.
Neurovascularly, the lower extremities were intact.
The examiner noted the results of the July 2005 MRI of the
right shoulder and back. The veteran was diagnosed with
impingement syndrome of the right shoulder with tear of the
supraspinatus and degenerative spondyloarthritis of the
lumbar spine with spinal stenosis and slight bulging disc.
III. Right shoulder impingement
The RO has assigned the veteran's 20 percent evaluation under
38 C.F.R. § 4.71a, Diagnostic Code 5201. As the veteran is
right handed, the criteria for a major joint apply.
Under Diagnostic Code 5201, a 20 percent evaluation is
assigned for limitation of motion of a major arm at shoulder
level. A 30 percent evaluation is in order for limitation of
motion of the arm midway between the side and shoulder
level. A 40 percent evaluation contemplates limitation of
motion of the arm to 25 degrees from the side.
The Board has applied all of the noted criteria to the case
at hand. However, the veteran's symptomatology (forward
flexion to 130 degrees; abduction to 130 degrees; external
rotation to 90 degrees; and internal rotation 45 degrees)
cannot equate to limitation of motion of the arm midway
between side and shoulder level. Thus an evaluation in
excess of 20 percent is not warranted.
The Board is aware the veteran experienced pain which limited
his range of motion. However, this pain is not shown to
limit the veteran's range of movement to a point midway
between side and shoulder level.
There is no evidence of favorable anklyosis of the
scapulohumeral articulation with abduction limited to 60
degrees or recurrent dislocation of the shoulder at the
scapulohumeral joint. Thus, no other criteria contemplating
the shoulder joint allow for an evaluation in excess of 20
percent.
Overall, the preponderance of the evidence is against the
claim for an evaluation in excess of 20 percent for the
service-connected right shoulder disability. Accordingly,
the appeal is denied.
IV. Lumbosacral strain
During the pendency of this appeal, the criteria for
evaluating spine disorders, including those involving the
lumbar spine have been substantially revised. Criteria for
evaluating spine disorders manifested by intervertebral disc
syndrome were revised effective on September 23, 2002.
The diagnostic criteria for evaluating spine disorders have
recently been revised, effective on September 26, 2003. This
further revision incorporates the new criteria for evaluating
intervertebral disc syndrome. 68 Fed. Reg. 51454-51458
(August 27, 2003).
Under the prior criteria of 38 C.F.R. § 4.71a, Diagnostic
Code 5295 (2003), addressing lumbosacral strain, a 20 percent
evaluation was warranted for muscle spasm on extreme forward
bending and loss of lateral spine motion, unilateral, in the
standing position.
A 40 percent evaluation was in order for severe lumbosacral
strain, with listing of the whole spine to the opposite side,
positive Goldthwaite's sign, marked limitation of forward
bending in a standing position, loss of lateral motion with
osteoarthritic changes, or narrowing or irregularity of joint
space, or some of the above with abnormal mobility on forced
motion.
Under the recent revisions (Diagnostic Codes 5235-5242), a 20
percent evaluation is warranted for forward flexion of the
thoracolumbar spine greater than 30 degrees but not greater
than 60 degrees; a combined range of motion of the
thoracolumbar spine not greater than 120 degrees; or muscle
spasm or guarding severe enough to result in an abnormal gait
or abnormal spinal contour such as scoliosis, reversed
lordosis or abnormal kyphosis.
A 40 percent evaluation is in order for forward flexion of
the thoracolumbar spine 30 degrees or less or favorable
ankylosis of the entire thoracolumbar spine. A 50 percent
evaluation is in order for unfavorable ankylosis of the
entire thoracolumbar spine. A 100 percent evaluation
contemplates unfavorable ankylosis of the entire spine.
Also, under these revisions, the "combined range of motion"
refers to the sum of forward flexion, extension, left and
right lateral flexion and left and right rotation.
The normal combined range of motion of the thoracolumbar
spine is 240 degrees. Associated objective neurological
abnormalities (e.g., bladder and bowel impairment) are to be
evaluated separately. The section for intervertebral disc
syndrome is now 5243.
The Board notes when a veteran's claim is pending at the time
that regulatory amendments are made to the applicable
diagnostic code sections, he is entitled to application of
the rating criteria most favorable to his claim. Diorio v.
Nicholson, No. 03-1889 (U.S. Vet. App. July 18, 2006).
However, given the symptomatology (including flexion forward
of 70 degrees; extension of 20 degrees; lateral flexion of 30
degrees to the right and left respectively; and rotation of
30 degrees to the right and left respectively), there is no
evidence of severe lumbosacral strain as contemplated by the
old provision of Diagnostic Code 5295. 38 C.F.R. §§ 4.40,
4.45.
Additionally, as there is no additional limitation of motion
after repetitive movement, or weakened movement, easy
fatigability, lack of endurance, or incoordination; nor did
the back pain interfere with activities of daily living; nor
does the veteran suffer from favorable ankylosis of the
lumbar spine, thus an evaluation in excess of 20 percent is
not warranted under any other provisions of the old
diagnostic criteria contemplating the lumbar spine.
38 C.F.R. § 4.71a, Diagnostic Codes 5285-5295 (2003).
Under the new criteria, the Board is unable to find evidence
that he is suffering from a disability picture consistent
with forward flexion of the thoracolumbar spine 30 degrees or
less or intervertebral disc syndrome manifested by periods of
incapacitating episodes that last at least 2 weeks in the
past year. Thus, an evaluation in excess of 20 percent
cannot be applied under the revised criteria either.
Overall, the preponderance of the evidence is against the
veteran's claim for an evaluation in excess of 20 percent for
the service-connected lumbosacral strain. Accordingly the
appeal is denied.
ORDER
An increased rating in excess of 20 percent for the service-
connected right shoulder impingement is denied.
An increased rating in excess of 20 percent for the service-
connected lumbosacral strain is denied.
____________________________________________
STEPHEN L. WILKINS
Veterans Law Judge, Board of Veterans' Appeals
Department of Veterans Affairs